=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700028560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SISKIYOU PROFESSIONAL MEDICAL SERVICE, PROF. CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2009
-----------------------------------------------------
Last Update Date | 03/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6736 QUAIL RUN ROAD
-----------------------------------------------------
City | YREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96097-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-842-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1667
-----------------------------------------------------
City | YREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96097-3450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-842-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ARVID R. MAGNUSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 530-842-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------